The Nursing Ethics Blog

There has been a great deal in the news over the last month or so about end-of-life care and the initiation and use of do-not-resuscitate orders. Two separate cases, both at Sunnybrook Health Sciences Centre in Toronto, have highlighted the challenges when the views of the health care team and those of the patient and family are in conflict at the end-of-life. On September 4th, the case of Douglas (Dude) DeGuerre and his daughter Joy Wawrzyniak was highlighted in an article in the Toronto Star. More recently, Mann Kee Li‘s case has been featured.

Li, a 46-year-old Toronto accountant and father of two young boys, wants doctors to use all medical measures possible to save him in the event of a life-threatening emergency.He made those intentions clear to his doctors at Sunnybrook Health Sciences Centre when he entered the hospital in August. He wrote it in a power of attorney document and confirmed it in a videotape statement, his lawyers say. While his doctor initially agreed to respect those wishes, physicians unilaterally reversed the decision a week ago without consultation and imposed a “do not resuscitate” order, his family alleges.

These two cases have a couple of common characteristics. First, the journalists have stated that the values and wishes of the patient/family and the health care team have been in conflict. Second, the families of the patients have stated that they were not included in decision-making regarding end-of-life care and more specifically, the lack of aggressive life-saving care that would be provided at the end-of-life.

Interestingly, a while after these two stories appeared in the news, I saw this headline on CBC news: DNR Orders Must be Discussed. Frankly, I’m not sure when the decision was made to stop talking to patients about end of life issues or DNR orders. Each of the patients’ cases in the stories above emphasize that decisions regarding DNR orders were not discussed with the patients or families. The fact that families feel that they haven’t felt that they’ve been part of the decision-making processes regarding end-of-life care and wishes, means that something is definitely wrong with how the health care team is functioning, at a very basic level. What these patients’ and families’ stories are really about are communication and values. One thing I couldn’t help thinking as I read these two patients’ stories was: Weren’t the nurses talking about these issues with the patients and families? Isn’t it inevitable that they would have been asked to? If so, what happened?

There are significantly troubling issues that arise out of these cases — too many to address in one blog entry. There are entire courses on the ethical issues surrounding end-of-life care. To do these issues justice, one requires more than a blog entry, even a very long one. So let’s just consider the issue of communication and the role of the nurse in these types of cases. While nurses may not be able to write the actual DNR order in most jurisdictions, they are, many times, the ones that patients and families turn to, in order to talk about what a DNR order really means. Nurses are also the ones that patients and families turn to when they fear that their values and wishes will not be either honoured or respected. Often, the bedside nurse is seen as a much less intimidating confidante than the physician. In my own experience working in cardiac surgery, there were many times I watched as caring and communicative surgeons obtained informed consent from calm, agreeable and seemingly very willing patients for surgical procedures, only to have those same patients (and families) voice doubt, fear and confusion to me moments after the surgeons left. By virtue of a number of factors (clinical distance and proximity, time spent at the bedside, intimacy of care provided, accessibility, knowledge and skills), it remains that nurses are often still the ones who patients and families seek out, in times of intense personal crisis.

In turn, nurses have a unique responsibility to patients and families, in situations of value conflict or crisis. When patients or families feel that they do not ‘have a voice’, nurses need to advocate for them. This doesn’t mean that a nurse must ‘take a side’ or necessarily agree with the patient, the family or the physician. This obligation is one that exists regardless of the context, and is essentially a professional and ethical responsibility.

In one Canadian document regarding end of life care, the Canadian Nurses Association Position Statement on Providing Nursing Care At The End Of Life (2008), it’s easy to see that the nurse has a number of responsibilities when it comes to providing end-of-life care, but a very important one is collaboration between all involved to foster an approach that is holistic, respectful of diverse values and based on consistent and meaningful communication. Here’s an excerpt:

Quality end-of life care is “best provided through the collaborative practice of an interdisciplinary team to meet the physical, emotional, social and spiritual needs of the person and their family.” Nurses, as members of the interprofessional team, collaborate with the person, the person’s family and all those involved in providing care (such as physicians, other health-care professionals and volunteers) to support a holistic approach; incorporate the person’s priorities, values and choices in all aspects of care; and address any specific concerns that may arise….

…Nurses are uniquely situated to develop therapeutic relationships with dying people and their families. Nurses who provide care at the end of life are witness to, and part of, a complex process that is physically, psychologically, emotionally and spiritually intimate and profound for most individuals, their families and their health-care providers.

It’s far too easy to ‘doctor-bash’ and claim that the physicians made decisions without including the values and wishes of the families and patients involved and that all the blame should be put on the doctors involved. However, everyone on the interdisciplinary team shares the responsibilities for ensuring holistic and collaborative care along with effective and therapeutic communication. When values conflict, everyone on the team knows – and action must be taken to encourage communication by everyone involved. I’m certainly not saying that there is any kind of easy answer — “Simply speak up for the patient and everything will be fixed!” — but I do think that the obligation to advocate for the patient and to ensure that communication is ongoing within the health care team is a very weighty one, and one that nurses must take on.

Why a nursing ethics blog?

This seems like an obvious question for the topic of a first blog entry. Why write a nursing ethics blog? Between Chris MacDonald and myself, we already have four blogs on ethics that keep us busy in addition to our academic and professional work. Why take on something more?

Well, simply put, there are two reasons for deciding to write a nursing ethics blog. First, there is a need. Nurses, in my experience, at all stages of professional life, have both a strong need and a yearning to have a place to read and talk about ethical challenges and issues that arise in practice. The classes I teach on ethics are always the ones in which there is the most active and engaged discussion, the most sharing of individual stories and the times when I receive the most after-class emails following up on topics, issues and cases. While presenting Dax Cowart as a case study might seem like old news to some bioethics colleagues, this case, as one example, is something that, year after year, my nursing students find compelling, troubling and worthy of reflection and intense discussion.

Second, there are nursing blogs out there, for sure. There are also plenty of nursing websites that contribute to nursing knowledge and have sections on ethics. There is also high quality, innovative work being done at the boundaries between social media and nursing, like Rob Fraser’s website, Nursing Ideas. But there isn’t anything that I can find that merges consistent and informed commentary on issues in health care, bioethics and nursing ethics in the way I have tried to do on the Research Ethics Blog (which was built on the advisory expertise of Chris MacDonald’s Business Ethics Blog, Biotech Ethics Blog and Food Ethics Blog).

On this blog, we’re aiming to try to discuss issues that are relevant and meaningful to nurses in modern practice today — nurses at the bedside, in administrative positions, in academia, in settings from intensive care units in busy downtown hospitals to rural and remote positions. We hope it will be a place where broader issues in health care and bioethics can be explored. We’re also hoping to write about enduring issues in nursing ethics like moral distress, moral integrity, empowerment, and professional stress, but write about these issues in an accessible, straightforward yet innovative and modern way.

This doesn’t mean we’re only going to write about issues “at the bedside”. Clearly, there is a strong element of interdisciplinarity and interprofessional work in nursing. So to ignore stories and issues in medical ethics or more generally, health care ethics, would not be a wise or prudent decision. Here are some examples: ethical issues that are prevalent in areas like end-of-life care, beginning of life care, resource allocation, and decision-making will be addressed here as will concepts such as morally problematic practices, consent, autonomy and the value of professional advice.

Above all, we’re simply hoping to engage scholars, students, and nurses at a variety of stages in their professional lives tackling difficult and complex issues in ethics. We hope you’ll check in and see what we’re doing!